Rose Hollingworth

HM Coroner Jonathan Stevens 
St Pancras Coroner’s Court 
Camley Street 
London 
N1C 4PP 

3 May 2024  

Care Quality Commission 

Dear HM Coroner Stevens,  

Prevention of future death report following inquest into the death of Rose 
Hollingworth. 

Thank you for addressing your Regulation 28 prevention of future deaths report 
(PFD) to the Care Quality Commission (‘the Commission’) following the inquest into 
the death of Rose Hollingworth.  

This letter represents the Commission’s formal response to your PFD report. 

In response to the death of Rosie Hollingworth, the Commission carried out a 
comprehensive inspection of HomeDotCare Limited in November 2022 with the 
attached report published in February 2023. The service was rated ‘Good’ overall. 

During this inspection we found action had already been taken to mitigate risk, 
specifically: 

•  There was evidence of learning from incidents and improving practice as a 

result. Examples of this included:  

Individual fire risk assessments 

o 
o  A policy to wake up a sleeping person to check on their health ('sleep 

protocol') 

o  A policy to inform next of kin of when a person had to go to hospital 

even if person was not admitted and a new orientation training for staff 
(p8 of the attached inspection report of HomeDotCare Limited: 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Assessing risk, safety monitoring and management; Learning lessons 
when things go wrong). 

o  Staff training also covered how to respond in an emergency. We asked 
some new staff if they knew who to call in an emergency and what to 
do if they found a person unwell. They knew what action to take and 
said the training had been helpful. 

o  Staff did not have first aid training and the registered manager 
arranged this immediately after the inspection for all staff 
(p10 of the inspection report, Staff support: induction, training, skills 
and experience). 

o  There was evidence of a culture of continuous learning and 

improvement. The registered manager was able to demonstrate 
learning from incidents which led to improvements in safety and quality 
of care provided. These improvements included improved training 
before staff started working with people and the introduction of a ‘sleep 
protocol’. This was a procedure for staff to follow if they found their 
client asleep on arrival and required them to gently wake the person 
and ensure they were well. Staff were aware of this protocol and able 
to explain clearly to us the action they were expected to take 

o  (p16, Managers and staff being clear about their roles, and 

understanding quality performance, risks and regulatory requirements; 
Continuous learning and improving care). 

o  As with all services regulated by the Commission, HomeDotCare 
Limited continues to be monitored and should concerns arise, this 
could prompt a responsive assessment if necessary. No immediate 
action is proposed. 

Given the action already taken by the Commission, we are reassured that 
HomeDotCare Limited have responded appropriately in response to the death of 
Rose Hollingworth. We have not seen evidence to suggest the concerns mentioned 
in section 5 of the regulation 28 report remain. 

For completeness, the CQC National Investigations team have also been looking 
into the death of Rose Hollingworth specifically, this investigation is ongoing, and the 
outcome will be shared with the coroner separately, once complete.  

Yours sincerely 

Deputy Director of Operations- London and East of England Network

Personal Assistant to Senior Coroner 
Supporting Communities 
London N1C 4AG 

1st May 2024 

Prevention of future death report following inquest into the death of 
Rose Hollingworth 

Dear Sir, 

Following the recently issued Regulation 28 Report to Prevent Future 
Deaths Rose Mary Hollingworth (Died 04/01/2022) on the 8th of March 
2024, I write to the Coroner with actions taken to reduce the risk of a 
similar incident occurring. 

For ease of reference, I have outlined the matters highlighted in the 
prevention of future death report and our responses: 

A. The carer should have conducted a proper welfare check on 

her first care visit 

The carer IE did call the office in the morning to report she had met 
the client asleep in bed. At that time, she believed the client was 
having a lie-in as she was snoring. The carer has stated that if she 
had not heard her snoring, it may have prompted her to check 
further and elicited a response from the client. The sound of 
snoring understandably re-assured the carer IE that the client was 
sleeping. Carer IE did not at that point think there was anything 
wrong as she was aware that the client had complained before of 
poor sleep during the nights and not getting enough sleep. She 
followed protocol by calling the office to report this as she met the 
client asleep at her first visit. Her intention was that when she 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 returned for the lunch visit, she would support the client with any 
tasks required that the client had been unable to do, knowing that 
the client was fairly independent with her care.  

•  We now have a sleeping protocol in place which is discussed at 

the induction and the 2-day additional orientation training and initial 
face to face supervision, the latter, which normally happens within 
2 weeks of care staff starting work.  Regular supervisions follow 
which takes place every 3 months. The sleeping protocol is a 
protocol to be followed by all staff when they meet a client asleep. 
It covers a set of instructions to follow to ascertain that the client is 
gently woken up to establish that they are well and responsive.  

•  We have also created a Good Guidance brochure highlighting the 
Sleeping protocol and what to do in an emergency. This brochure 
has been circulated to all staff and is signed and dated to evidence 
their understanding of care practices highlighted.  

•  These matters are also discussed at their performance reviews 

and checked against their care note audits or if we are notified of a 
no reply.  

•  Care workers are constantly reminded by way of communication 
on platforms, memos, newsletters, supervisions and spot checks 
to always call emergency services first and not leave the client 
alone.  

•  Carers are also knowledge checked of their understanding of the 
sleeping protocol when spot checks and supervisions take place. 

•  Field care supervisors take the time to explain the sleeping 

protocol to new clients at initial assessments and at ongoing client 
reviews. If a client refuses for HomeDot Care to carry out the 
sleeping protocol, we will then in turn inform the local authority and 
seek further guidance.  

 Timeline: Implemented January 2022 

 
 
 
 
 
 
 
 
 
 
 
 B. The carer should have been concerned that RH was not up 

and waiting for the arrival of her carer as she normally would 
have been. 

Carer in her defence had said that because Rose Hollingworth had 
complained of not sleeping well at nights, she did not think it alarming to 
find her still asleep as she had assumed she was still sleeping and as 
the client was making a snoring noise, she thought she was in a deep 
sleep. 

•  However, since that incident we have implemented the sleeping 
protocol and insisted that they gently wake the client if they 
find them asleep on arrival and ascertain that they are alive 
and responsive. 

•  This is frequently discussed during training, supervisions and spot 

checks. 

•  Carers are trained to spot changes in client’s usual routines and 

follow the above process. 

•  As management we are re-assured that this is actually being 

carried out by our staff as we had a similar incident for another 
client named RH who sadly passed away. Care worker found him 
‘asleep’ and carried out the sleeping protocol and the emergency 
contact procedure.  

Timeline: Implemented January 2022 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 C. The carer should have checked Rose Hollingworth’s catheter 

bag which was later found to have 1-2 days of urine 

Rose Hollingworth was independent managing her catheter care and 
catheter care management was not a task on the support plan meaning 
that it wasn’t a responsibility for the carers to do. That said, one can see 
reading the care notes that when carers visited and sometimes observed 
that the bag needed to be emptied, they assisted her with this. This 
belies the care assessment that Rose was able to manage her day-to-
day catheter care (emptying the bag) independently.  
The care notes available indicate that the catheter bag was checked the 
day before the serious incident.  

That said, we have taken learning from this incident and the following 
has been put in place:  

•  If the client is managing their own catheter care (and not part of 
the support plan) care workers are still trained and instructed to 
observe and report any concerns such as client not managing 
properly and we in turn can then escalate this to Social Services or 
make a GP referral if this could turn medical 

•  Carers now receive specialist training on catheter management to 
indicate smell, colour, volume output and any other concerns that 
may be picked up. They are also trained to empty and change 
bags. This is a practical one to one in-house training which sits 
alongside their Care skills theoretical catheter training. 

•  We have a dedicated monitoring team who have the list of all 

clients with catheter care and who check the care notes and flag to 
the internal office team if the above parameters are not being met / 
reported.  

•  This is further discussed at supervisions and knowledge checked 
at spot-checks by field care supervisors who provide further 
guidance if needed.  

 
 
 
 
 
 
 
 
 
 
 
 •  If concerns are picked, the care worker is referred to the in-house 

trainer to re-train them on the field. 

Timeline: Implemented April 2022 

D. The care worker should have made sure that RH took her 

medication 

The medication task on the support plan for Rose Hollingworth was 
prompt and albeit the carer IE was not using recording involvement 
correctly, there is no evidence of medication backing up or not being 
taken. None of the other care workers attending to this client noticed 
medication being left or not given. The field care supervisor visited on at 
least 2 occasions and did not see any evidence of medication being 
backed up. 

This said, the following practices have been further re-iterated and are 
being monitored:  

•  We ensure that carers undertake full medication training and this is 
done in a variety of ways through their Care Certificate, Induction 
training, Orientation training and medication competency in the 
field. This is then followed at a later stage with their attendance at 
a refresher medication clinic to ensure that they are following good 
medication care practices 

•  The carer is also trained to know the difference between 
medication prompt and medication administration and act 
accordingly 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 •  Our ECM Team monitor the care notes to ensure that carers use 

the appropriate medication terms so that it isn’t conflicting with the 
original medication task 

•  There is prompt monitoring by a dedicated field care supervisor of 
all medication alerts and checking for changes, discrepancies or 
missed medication. 

•  We also undertake medication audits every 6 months. 

•  Carers are trained and instructed to always record their medication 
prompt and administration activities on their app which will provide 
evidence that they have undertaken this task 

•  Any concerns picked up on a daily basis are shared with the DN, 

GP, pharmacist  

Timeline: Implemented February 2022 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 E. The care worker should not have been told by HomeDot Care 
when she called to leave Rose Hollingworth and return at 
lunch time 

The out of hours officer had advised the carer to leave as it was known 
that Rose Hollingworth did not like early morning care visits and had 
trouble sleeping at nights and sometimes liked to have a lie-in. Carer 
had communicated she was asleep and snoring, so the assumption was 
made that she was asleep. There have been clients who would like to 
have a lie-in as they have had a bad night of sleep and may not want on 
that occasion to have an early morning visit. If they had a follow-up visit 
in the day, we would ensure that tasks unable to be carried out for the 
morning visit would be undertaken later that day. This would apply to 
clients independent with their care. As an organisation we have taken 
lessons from this and the following is now in place:  

•  At the back of this incident, we have introduced the sleeping 

protocol which would mean that no assumptions are made based 
on someone’s routine or observations. 

•  The sleeping protocol allows an effective process to be followed to 
ensure that when a client is met asleep in bed, that they are gently 
woken up to ascertain that they are well and responsive. 

•  We have re-trained our internal and out of hours team to adhere to 

that process when advising care workers who may call in 
regarding something similar  

•  We further re-iterate the importance of due diligence and safe 

practices by way of memos and newsletters 

Timeline: Implemented January 2022 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 F.  The carer should have provided basic first aid at the scene 

At that time our care staff were not trained to give practical first aid and it 
would have been the expectation for them to call the emergency 
services which she did. 

At the back of our CQC visit in November 2022 we did discuss this with 
our visiting CQC inspector and as part of her recommendation we have 
trained all staff in Life Support with anaphylaxis and AED. 

This is a training that every member of staff has undertaken and is 
certified and is part of on-going recruitment training. We have a 100% 
compliance with care workers now trained up and certified and this 
training is done before they start work.  

We also check in to see if they are confident and if need be, we re-enrol 
them for them additional training. 

Timeline: Implemented November 2022 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 G. The carer assigned on the 3rd of January 2022 was a Somalian 
speaking care worker who required a Somalian translator in 
order for her to give evidence raising concerns that the carer 
lacked the ability to properly and safely communicate with 
Rose Hollingworth in English when attending to her care 
needs 

During the recruitment process and during the time she worked at 
HomeDot Care, the carer IE was able to communicate and understand 
information in English shared between the care agency and herself. All 
staff communicated with her in English and her standard was a 
reasonable to good level and therefore there were no concerns about 
her ability to communicate in English to clients. 

The care coordinator has in her statement testified that on the two 
occasions she spoke to RH, the latter was complimentary about her 
carer IE and the service provided and raised no concerns about a 
language barrier. 

The carer has always stated that due to it being a coroner’s court 
hearing and legal proceedings, she felt more comfortable having an 
interpreter to fully understand the nuances of proceedings as English is 
not her first language.  

As an equal opportunities and non-discriminatory employer, we as an 
organisation recruit staff from various backgrounds and ethnicities who 
also represent our clientele base as long as they speak reasonable to 
good English and can make themselves understood. 

Coroners Concerns: 

There was a failure to provide suitably trained, experienced and 
competent carers for a vulnerable person depending on the 
package of care 

Carer IE was the care worker primarily involved with RH. We have 
indicated our view that training was given in accordance with our policies 

 
 
 
 
 
 
 
 
 
 
 at the time and were given to understand that IE had previous care 
experience. 

As a standard ongoing practice, we now ensure that our recruitment and 
training process covers the following: 

•  Care Certificate training that needs to be completed before the 

induction training 

•  2 full days of Orientation training which covers in-depth care 
operational practices, care systems, practical medication 
demonstration, future safety catheter care, emergency procedures, 
pressure sores, etc. 

•  2 full days induction training 

•  1 full day manual handling and First aid training with anaphylaxis 

and AEB 

•  3 to 5 days shadowing based on experience with a senor care 

worker 

•  1 day with a field care supervisor with feedback given to 

management and completion of shadowing certificate checklist, 
medication competency and an eventual sign-off to evidence 
community care competency 

•  This is followed by a face-to-face supervision within 2 to 3 weeks 
of start of work to discuss how confident they feel working in the 
community and above training and support received to date 

•  They attend a refresher medication clinic to ensure that good 

practices are being followed 

•  We provide specialist training for our staff such as Stoma Care and 
Tracheostomy, Epilepsy with Buccal administration, Peg Feeding, 
Mental Health, Mental Health First Aider, Learning Disabilities and 
Autism, Oral Suctioning and Dysphagia, etc. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 Timeline: Implemented April 2022 

H. There was a failure to properly supervise and manage the 

carers 

At the time of the incident, we were in the middle of the second Corona 
virus wave which resulted in quite a number of staff being off sick after 
testing positive including RH’s care worker 

This meant carer IE worked for 2 weeks with the client and then went off 
sick to start with her again on the 3rd of January 2022 when this serious 
incident took place. 

The following is now in place: 

•  1st initial supervision 2 weeks within commencing the role 

Monitoring of the carers now comprises of the following checks: 

•  Daily monitoring by a dedicated ECM Team to check accurate log-

ins using NFC for geo-fencing 

•  Checking quality of care notes by using a care worker compliance 

audit form covering task completion tasks such: 

(visit duration, personal care, catheter management, 
medication, pressure sore, food preparation, leaving 
arrangements, etc) 

•  Carers have approximately 2 weeks plus of training and are signed 

off before they are signed off to work in the community 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 •  Ongoing and on demand in-house training such as 121 medication 

training, catheter care training 

•  When concerns are up by the ECM Team / Care Coordinators / 
clients feedback / Nok / Field Care supervisors, we carry out a 
response to Concern meeting and agree improvement actions to 
discuss / advise and check if re-training is required 

Timeline: Implemented April 2022 

I.  The care and support plan was not properly completed and 

contained significant errors 

We have not been made aware that there were significant errors with the 
care assessment completed by HomeDot Care and are not sure if the 
above is in reference to HomeDot Care’s care assessment. However, 
we have continued to improve upon the care assessment planning 
process and we have done this by: 

•  Re-training of our field care supervisors to undertake more in-

depth person-centred care assessments to capture any gaps that 
may not have been covered within the original support plan 
received by the local authority 

•  Specialist risk assessments once complex needs are identified 

such as clients with choking risks, breathing issues, Parkinsons, 
diabetes, epilepsy, etc. 

•  If and when we identify any additional needs or support required, 
we feed then back to the local authority requesting an updated 
support plan 

Timeline: Implemented February 2022 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 J.  There was a failure to properly monitor, review and manage 

and check the performance of the care agency 

Whilst this is directed towards the CQC and Islington, it is to be noted 
that there was a challenge presented with on-site visits due to the 
pandemic and being in the second wave when this serious incident 
happened. 

At the back of this incident, we have since had Islington Social Services 
carry out 2 comprehensive inspections, one in May 2022 and again in 
June 2023 with the next due later this summer of 2024. 

We also have had a CQC inspection in November 2023 for which we 
were rated overall Good and all above concerns were looked into and 
addressed with lessons learnt shared. 

As an organisation, we are committed to continuous improvement in 
providing safe and effective services and have committed to having 
annual Mock Inspections with a care consultancy company.  

As part of our on-going governance review, we have introduced further 
improvement actions within the organisation which include and are not 
limited to: 

•  Internal and community staff being made clear on job roles and 
areas of responsibilities to effectively and safely carry out their 
roles 

•  Fully transitioning to electronic care recording systems and 

subsequent day to day monitoring of this 

•  Regular reviewing of policies and processes 

•  Expanding on our training offer 

 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 •  Dedicated team of officers for monitoring purposes 

•  Ongoing sharing of lessons learnt and reviewing CQC serious 

incidents (for further learning and improvement actions) 

•  Widening our auditing scope 

•  Investing in annual mock inspections 

We hope above actions demonstrate how serious we have taken the 
recommendations and have acted promptly and decisively to prevent a 
similar incident from happening again.  

Sincere regards, 

Registered Manager

HM Coroner Jonathan Stevens  
St Pancras Coroner’s Court  
Camley Street 
London N1C 4PP 

Adult Social Care  
4th Floor  
222 Upper Street 
London N1 1XR 

By email only 

14 May 2024 – sent on 30 May. 

Dear Coroner Stevens, 

London Borough of Islington response to the Regulation 28 Prevention of future death 
report into the death of Rose Hollingworth 

In response to the matter of concerns of the PFD that there was a failure to properly review, 
manage and check the performance of the care agency, Islington’s response is the following: 

The Council’s Adult Social Care vision is for Islington to be a place made up of strong, inclusive, 
and connected communities, where regardless of background, people have fair and equal 
access to adult social care support that enables residents to live healthy, fulfilling and 
independent lives. This vision underpins all our activity, and we expect our providers that we 
commission to embrace this approach.  
Adult Social Care commission providers to support residents on a range of services, this 
includes placements in care homes and supported living, advocacy services and home care 
services.  

Adult Social Care have a dedicated team of 8 people who are employed to manage their 
contracts, this includes checking the quality of our providers who we commission with, ensuring 
they are delivering on their agreed key performance indicators. The team work alongside other 
teams to develop a holistic understanding of a provider. This includes social workers, 
occupational therapists, health colleagues and contract managers from other local authorities.  

Islington Council has a robust process in place to monitor the quality of care of our providers. 
We work closely with CQC and across the system to ensure a system wide approach. This is 
overseen by the Islington Provider Quality Oversight Board (IPQOB), which reports to the 
Senior Leadership Team within Adult Social Care and the Independent Adults Safeguarding 
Board.  

The Islington Provider Quality Oversight Board is a monthly multi-agency meeting with 
colleagues from across health and social care and CQC in attendance. The role of the board is 
to work in partnership with health and CQC to triangulate information about providers where 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 there are concerns from across agencies. The Board shares intelligence and agrees key actions 
to support provider improvement and ensure residents are safe. Providers are risk rated based 
on agreed criteria. Providers on the IPQOB agenda, receive enhanced monitoring, oversight 
and support from an allocated contract officer employed by London Borough of Islington.  

Where providers are found not to be performing well, the Council can enact its Provider 
Concerns Process. This process is supported by CQC who attend meetings.  
The process supports the provider to identify areas of improvement. 

Further, it seeks assurances that these changes are embedded to ensure that Islington 
residents are receiving safe care. Where a provider is not assessed to be making the necessary 
changes to ensure a safe service, the Council may then seek to move individuals to another 
provider. This board reports to the Islington Safeguarding Adults Partnership Board so that the 
whole system can review and consider concerns, this has also helped refine the process to 
ensure we are effectively capturing and addressing concerns.  

The council undertakes an annual audit of home care providers. The audit is based on CQC 
Key Lines of Enquiry, which provides robust assurance around the suitability of providers who 
work with Islington residents. This includes reviewing the care plans, staff files and reviewing 
key policies to ensure that people are receiving a safe service in line with the standards.   

The council leads quarterly provider forums with the aims of fostering a supportive learning 
environment to share, reflect and shape best practice across the sector. It’s also an opportunity 
to hear from commissioning colleagues any key trends and important information to share 
including presentations  from other areas to share learning and commissioners share important 
information and key trends. The forum is supplemented by a regular provider bulletin, which  
provides updates and news stories that may be of interest to providers, as well as reminders of 
changes in regulation. 

Contracts and commissioning colleagues work closely with safeguarding and operational social 
work teams to share intelligence about providers, to ensure a coordinated approach to decision 
making and agreeing the proportionate approach to address concerns.  Operations colleagues 
submit “service issues” to providers where they have identified issues with an individual’s 
package of care. The provider is expected to investigate and report back to the Council within 
10 days. Service issues are a useful source of intelligence to identify if there are wider quality 
concerns about a provider. This process also enables general trends to be identified, which feed 
into provider forums to share learning that may be useful for all home care providers.  

During 2023, the Council undertook a robust procurement exercise for a new home care service 
through a framework, to replace the previous contracts which expired in March 2024. The 
procurement aimed to reduce the number of providers London Borough of Islington uses, 

2 

 
 
 
 
 
 
 
 enabling the council to work more closely with a smaller number of providers and further 
enhance the focus on quality and safety of residents. The procurement exercise was extensive 
and included site visits and interviews with prospective providers. Residents were also part of 
the procurement evaluation panel. The new framework went live on 1 April 2024 with 9 locality 
providers and 14 secondary providers.  

Learning and strengthening practice 
All providers commissioned by Islington Council are expected to be on a journey of continuous 
improvement, and the contracts and commissioning functions in the Adults Social Care 
Strategic Commissioning and Investment Department also take this approach within their own 
practice.    

ASC continues to review their process for contracting and quality monitoring. The Council have 
updated their provider audit approach to include resident and staff voice in the process. This 
forms part of the Quality Assurance Framework, which has recently been reviewed.  
London Borough Islington continues to work closely with other London councils  and responds 
to concerns from host boroughs, regarding providers supporting Islington residents, where we 
have placed individuals or where we are the lead authority.  
Contracts and commissioning functions are always included in any learning, strengthening of 
practice and service improvements being made across the department.  This includes 
membership on the Prevention and Learning subgroup of the Safeguarding Adults Board.  

Yours sincerely, 

Director of Adult Social Care 
Islington Council 

3

HM Assistant Coroner Mr J. Stevens 
St Pancras Coroner’s Court 
Camley Street 
London N1C 4PP 

First by email & 1st Class Post 

Law and Governance 
Islington Council 
222 Upper Street 
London N1 1XR 

Date: 13 May 2024 sent on 6 June 2024 

Dear Sirs, 

Letter before claim for Judicial Review concerning procedural irregularity around the 

Prevention of Future Death Report in the Rose Hollingworth Inquest 

This is a Letter Before Claim in accordance with the Pre Action Protocol for Judicial Review. 

Part 54 CPR and Part 54(a) of the Practice Direction are relevant. 

1 Proposed claim for judicial review 

To: HM Assistant Coroner Mr J. Stevens 

St Pancras Coroner’s Court 

Camley Street 

London N1C 4PP 

2 The claimant 

Islington Council  

Law and Governance 

Islington Council 

222 Upper Street 

London N1 1XR 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 3 The defendant’s reference details  

Inquest into the death of Rose Hollingworth heard by HMAC Mr Stevens on 25 & 26 July 2023 

and the Prevention of Future Death Report dated 8 March 2024 received by the Claimant on 22 

March 2024. 

4 The details of the claimants’ legal advisers dealing with this claim 

Senior Legal Services Officer  

Law and Governance 

Islington Council 

222 Upper Street 

London N1 1XR 

DX 122230 Upper Islington 

5 The details of the matter being challenged: 

1.  The matter under challenge is the Court’s failure to facilitate receiving submissions by the 

Claimant, pursuant to its own directions, and the consequent prevention of Future Death 

Report to the Claimant. 

2.  The Grounds for challenge are procedural irregularity. 

3.  On 26 July 2023, HM Coroner completed the inquest of Rose Hollingworth concluding 

that the cause of death was by natural causes and made the following directions. 

i.  The family to file their written submissions by 23.8.23 if they sought a PFD. 

ii.  LBI and Care agency to file their response by 20.9.23. 

4.  The Claimant, mindful of the importance of being heard, sent several emails to the Court 

to check if submissions from the family had been received by the Court and requested 

the court to send the famiy’s submissions. The Claimant sent emails on the following 

dates 04.09.23 – 12.09.23 – 02.10.23 -12.01.24 – 17.01.24 & letter 25.03.24 to which no 

response was received from the court office. The Claimant communicated to try to 

ensure that the directions were complied with, that it was able to make submissions and 

2 

 
 
 
 
 
 
 that these would be considered before the Court determined whether its duty to issue a 

PFD report was engaged. 

5.  The family submissions were dated 21.8.23. The Court had an obligation to serve those 

submissions on the other Interested Persons. There was no order for cross service of the 

same and that it not standard in the Coroners Court’s, as disclosure to and from the 

Court is via the court office. It is clear from the family submissions that they are critical of 

the Claimant and the care agency and would generate a written submission in response. 

6.  The Court failed to send the family submissions to either Interested Person (the care 

agency) to enable them to reply. Quite clearly from the family’s position and that which 

HM Coroner was therefore considering, it is reasonable for him to expect receipt of 

submissions from the Claimant in accordance with his directions. The absence of the 

same should have alerted him to the fact that his directions had not been met by 2 

Interested Persons, who can reasonably be expected to have made such submissions. 

The same should have caused him to check, that the IP’s had something to respond to, 

and that the court office had sent out the family submissions to the IPs. 

7.  The PFD Report was made a considerable time after the hearing, approximately 8 

months. The Chief Coroner’s Guidance 5, paragraph 38 states a report should be sent 

out within 10 working days of the inquest. Even on the timetable of the directions, any 

PFDR should have been issued within the first week in October 2023, not March 2024.  

8.  Additionally, the PFDR was made on 8 March 2024 but not sent to the Claimant until 22 

March 2024, amounting to further inexplicable delay. The significance of this is that there 

is a statutory period of 56 days in which to respond from the date of issue, and so the 

clock was run down by the Court issuing the Report 14 days after it was dated. 

9.  The procedural irregularity should not be confused with a matter of fact in a report which 

is disputed by an IP. The latter requires disputed facts to be responded to within the 

3 

 
 
 
 
 
 
 
 
 formal PFD reply. However, the procedural irregularity is the matter of greatest concern. 

The Court failed to send the family submissions to the IP’s, respond to repeated requests 

to see whether the same had been received, recognise that it was making a decision 

which excluded the IP’s from that process when they had a legitimate expectation to be 

heard, and went on to make a PFDR which, had the Court been in receipt of the latest 

position from the Claimant, would likely not have made a PFDR. 

10. The Claimant wrote to the Court on 25 March 2024 to express its concerns about 

receiving a PFDR out of the blue and was told,  

Your letter of 25th March 2024 has been referred to the coroner. The coroner officer that 

dealt with this matter has left the coronial service and the coroner confirms that he was 

unaware that the family's submissions had not been provided to the Council nor that they 

had written to the court requesting a copy. It was, of course, open to the council to also 

request a copy of the family’s submissions directly from the family, however, a copy is 

now attached. It is regrettable that the Council did not receive a copy of the family's PFD 

submissions, but the Council can still, of course, respond in full to the matters raised in 

the PFD in their response to that. The PFD issued arises out of evidence heard at the 

inquest. 

11. The response is perfunctory. It is not for the Claimant to go directly to the Family when it 

communicates with the Court and can expect a reply to comply with directions. The 

Coroner should have been made aware of whether the IP’s had received the 

submissions as a matter of court administration. The remedy is not to simply respond to 

the concerns as the Court cannot be confident that it has made the decision to issue a 

PFDR based on the current and best information nor that it has acted fairly in allowing 

the Claimant to be heard. Had it done so it is likely that the PFDR would have issued only 

against the care agency, about whom HM Coroner was critical in the inquest but he was 

not critical of the Claimant.  

12. It was important that HM Coroner had submissions in response. As a matter of 

transparency, IPs and the public must be confident that court processes and decision 

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 making are fair, that the Court facilities its own directions to enable compliance with them 

and that the court administration and resources support the role of the judges who make 

decisions, by communicating with IP’s responding to their correspondence.  

6 The details of any Interested Parties 

The other Interested Parties are: 

1.  The Family  

2.  Home dot care 

We confirm that they have been sent a copy of this letter. 

7. The details of the action that the defendant is expected to take 

Whilst the Court has no power to withdraw a PFDR, it is asked to consent to an application to 

the High Court for the decision to issue a PFDR against the Claimant to be quashed. For clarity, 

this would remove PFDR paragraph 5(4) which states there was a failure to monitor, review, 

manage and check the performance of the care agency and would remove the Claimant as a 

recipient. There would be no application for costs. 

9 ADR proposals 

We would welcome ADR or a meeting to try and resolve the matter via a Consent Order, if that 

is not readily forthcoming. 

10 Proposed reply date 

Please respond with 14 days of the date of this letter and by 26 June 2024. 

Yours faithfully 

Senior Legal Services Officer  
Mental Health First Aider - (Trained in Mental Health First Aid) 
Law & Governance 

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